A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)

Keep the client's bed in the lowest position.

Assess the client every 4 hr.

Keep the client's room dark at night.

Teach the client to use the call light.

Place a fall-risk identification band on the client's wrist.

Answer and Explanation

Correct Answer : A,D,E

A.   Keeping the client's bed in the lowest position helps minimize the potential fall distance if the client attempts to get out of bed.
B.   Assessing the client every 4 hours is a good practice for general monitoring but may not be specific to fall prevention. More frequent assessments may be necessary for a client at high risk for falls.
C.   Keeping the client's room dark at night can actually increase the risk of falls. It's important to ensure there is adequate lighting to help the client navigate safely.
D.   Teaching the client to use the call light allows them to request assistance when needed, reducing the likelihood of attempting to move or get out of bed independently.
E.   Placing a fall-risk identification band on the client's wrist helps alert all healthcare providers that the client is at risk for falls. This information is crucial for ensuring appropriate precautions are taken.

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Correct Answer is C

Explanation

A. Goggles are not typically necessary for droplet precautions unless there is a risk of splashing or spraying of respiratory secretions.
B. A gown is not specifically required for droplet precautions. However, if there is a risk of contamination from respiratory secretions, a gown may be used in addition to other precautions.
C. When setting up a meal tray for a client requiring droplet precautions, the nurse should wear a mask to protect against potential exposure to respiratory droplets.
D. Gloves are not typically required for setting up a meal tray under droplet precautions, as there is no direct contact with potentially contaminated surfaces.

A. Hypertension and crackles B. Fever and chills C. Excessive thirst and urination D. Shakiness and diaphoresis

Correct Answer is D

Explanation

a. Hypertension and crackles:

While hypertension can be associated with various conditions, such as cardiovascular diseases or stress, it is not directly related to the cessation of TPN infusion.

Crackles in the lungs are often indicative of fluid accumulation or inflammation, commonly seen in conditions like pneumonia or heart failure. They are not typically associated with the interruption of TPN infusion.

b. Fever and chills:

Fever and chills can be symptoms of infection or inflammatory processes in the body. However, they are not specifically related to the interruption of TPN infusion.

In the context of TPN cessation, the focus would be on metabolic changes rather than infectious processes.

c. Excessive thirst and urination:

Excessive thirst and urination are classic symptoms of hyperglycemia, which can occur when TPN, particularly if it contains a high glucose concentration, is abruptly interrupted.

When TPN infusion stops, there is no longer a continuous supply of glucose to the body, leading to increased blood glucose levels and subsequent polyuria (excessive urination) and polydipsia (excessive thirst) as the body tries to eliminate excess glucose.

d. Shakiness and diaphoresis:

Shakiness and diaphoresis (excessive sweating) are classic symptoms of hypoglycemia, which can occur if TPN, particularly if it contains a high concentration of insulin, is abruptly interrupted.

TPN solutions often contain glucose and insulin to maintain proper blood glucose levels. If the infusion is stopped suddenly, there may be a rapid decline in blood glucose levels, leading to hypoglycemia, which manifests as shakiness, diaphoresis, confusion, and other neuroglycopenic symptoms.

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A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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